RESUMEN
OBJECTIVES: To determine whether an acute fixation protocol for high-energy tibial pilon fractures increases the rate of wound complications. DESIGN: Retrospective comparative study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred forty-seven patients with OTA/AO 43B and 43C high-energy tibial pilon fractures treated with open reduction and internal fixation (ORIF). INTERVENTION: Acute (<48 hours) versus delayed ORIF protocols. MAIN OUTCOME MEASUREMENT: Wound complications, reoperations, time to fixation, operative costs, and hospital length of stay (LOS). Patients were compared by protocol, regardless of ORIF timing, for an intention-to-treat analysis. RESULTS: Thirty-five and 112 high-energy pilon fractures were treated under the acute and delayed ORIF protocols, respectively. In the acute ORIF protocol group, 82.9% of patients received acute ORIF versus 15.2% of patients in the standard delayed protocol group. The 2 groups had no observed difference (OD) in the rate of wound complications (OD -5.7%, confidence interval (95% CI) -16.1% to 7.8%; P = 0.56) or reoperations (OD -3.9%, 95% CI, -14.1% to 9.4%; P = 0.76). The acute ORIF protocol group had a shorter LOS (OD -2.0, 95% CI, -4.0 to 0.0; P = 0.02) and lower operative costs (OD $-2709.27, 95% CI, -3582.02 to -1601.16; P < 0.01). On multivariate analysis, wound complications were associated with open fractures (odds ratio 3.36, 95% CI, 1.06-10.69; P = 0.04) and an American Society of Anesthesiologists score >2 (odds ratio 3.68, 95% CI, 1.07-12.67; P = 0.04). CONCLUSION: This study suggests that an acute fixation protocol for high-energy pilon fractures decreases time to definitive fixation, lowers operative costs, and shortens hospital LOS without affecting wound complications or reoperations. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas de Tobillo , Fracturas de la Tibia , Humanos , Estudios Retrospectivos , Reoperación , Resultado del Tratamiento , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Fracturas de Tobillo/cirugíaRESUMEN
OBJECTIVES: To compare the early outcomes of patients with stress-positive minimally displaced lateral compression type 1 (LC1b) pelvic ring injuries managed with or without operative fixation. DESIGN: Retrospective comparison study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-three patients with LC1b injuries. INTERVENTION: Operative versus nonoperative. MAIN OUTCOME MEASUREMENTS: Discharge to subacute rehabilitation (SAR); 2- and 6-week pain visual analog score, opioid use, assistive device use, percentage of normal single assessment numerical evaluation, SAR status; fracture displacement; and complications. RESULTS: The operative group did not differ in age, gender, body mass index, high-energy mechanism, dynamic displacement stress radiographs, complete sacral fractures, Denis sacral fracture classification, Nakatani rami fracture classification, follow-up length, or American Society of Anesthesiologists classification. The operative group was less likely to be using an assistive device at 6 weeks [observed difference (OD) -53.9%, 95% confidence interval (CI) -74.3% to -20.6%, OD/CI 1.00, P = 0.0005], less likely to remain in an SAR at 2 weeks (OD -27.5%, CI, -50.0% to -2.7%, OD/CI 0.58, P = 0.02), and had less fracture displacement at follow-up radiographs (OD -5.0 mm, CI, -9.2 to -1.0 mm, OD/CI 0.61, P = 0.02). There were no other differences in outcomes between treatment groups. Complications occurred in 29.6% (n = 8/27) of the operative group compared with 25.0% (n = 4/16) of the nonoperative group resulting in 7 and 1 additional procedures, respectively. CONCLUSIONS: Operative treatment was associated with early benefits over nonoperative management, including shorter time using assistive devices, less SAR use, and less fracture displacement at follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas Óseas , Huesos Pélvicos , Fracturas de la Columna Vertebral , Humanos , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesiones , Estudios Retrospectivos , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Sacro/lesiones , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation. DESIGN: Retrospective comparative cohort. SETTING: Urban level-one trauma center. PATIENTS/PARTICIPANTS: LC1 injuries managed operatively. INTERVENTION: Anterior-posterior versus posterior-only fixation. MAIN OUTCOME MEASUREMENTS: Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up. RESULTS: Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups. CONCLUSION: Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas Óseas , Huesos Pélvicos , Fracturas de la Columna Vertebral , Humanos , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesiones , Estudios Retrospectivos , Fracturas Óseas/terapia , Fracturas de la Columna Vertebral/cirugía , Pelvis/lesiones , Fijación Interna de FracturasRESUMEN
OBJECTIVES: To determine the association of pelvic fracture displacement on lateral stress radiographs (LSRs) with the hospital course of patients with minimally displaced lateral compression type 1 (LC1) pelvic injuries. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Twenty-eight adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION: Nonoperative management. MAIN OUTCOME MEASUREMENTS: Delayed operative fixation, days to clear physical therapy, mobilization, hospital length of stay, and total hospital opioid morphine equivalent dose. RESULTS: LSR displacement was correlated with delayed operative fixation [r = 0.23, 95% confidence interval (CI) 0.05-1.11; P = 0.01], days to clear PT (r = 0.13, CI 0.01-0.28; P = 0.02), length of stay (r = 0.13, CI 0.006-0.26; P = 0.02), and opioid morphine equivalent dose (r = 19.4, CI 1.5-38.1; P = 0.03). A receiver operating characteristic curve for delayed operative fixation over LSR displacement had an area under the curve of 0.87. The LSR displacement threshold that maximized sensitivity and specificity for detecting patients who required delayed fixation was 10 mm (100% sensitivity and 78% specificity). Ten of the 15 patients with ≥10 mm of displacement on LSRs underwent delayed operative fixation for pain with mobilization at a median of 6 days (interquartile range 3.7-7.5). Patients with ≥10 mm of displacement on LSRs took longer to clear PT, took longer to walk 15 feet, had longer hospital stays, and used more opioids. CONCLUSIONS: LC1 fracture displacement on LSRs is associated with delayed operative fixation, difficulty mobilizing secondary to pain, longer hospital stays, and opioid use. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.